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The pack was assembled at the Boots branch in Orwell Road, Felixstowe.

It was then delivered to Mr Lamond’s home in Stuart Close in the town on May 10, 2012, and he died on May 12 at Ipswich Hospital.

Mr Smith said: “He told paramedics he had been short of breath for the last three days and had chest pain.”

Dispenser Susan Hazelwood had slit open a compartment of a previously assembled medicine box to add pills that had been requested and then sealed it with sticky tape, the inquest heard.

Mr Smith added: “She did not check the existing box to check it was in the name of Douglas Lamond.”

Another pharmacist at the Boots store – Mihaela Seceleanu – had checked the box for the additional pills, the inquest heard, but not for the existing ones.

However the Crown Prosecution Service said there was insufficient evidence to charge anybody with gross negligence manslaughter.

Ms Seceleanu was cautioned under the Medicines Act 1968.

Widower Mr Lamond was born in Dundee, had served in the RAF as a bomb aimer and navigator but lived alone at the time of his death.

The branch of Boots in Orwell Road stopped the assembly of medical packs in branch after the incident.

Daughter Dianne Moore said in a statement read to the hearing: “There’s, somewhere, a failing in the dispensing process that I would like to see investigated so another family doesn’t have to go through such a traumatic experience.”

The inquest continues, and is expected to last up to two weeks.

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